Free Agency Application for Access to Web-Based Personal Care Screening Tool - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-20418 (08/2008)

STATE OF WISCONSIN

AGENCY APPLICATION FOR ACCESS TO WEB-BASED PERSONAL CARE SCREENING TOOL
Completion of this form is voluntary. Failure to complete this form may result in a delay in gaining access to the web-based Personal Care Screening Tool. Application may only be submitted by Medicaid Certified Personal Care Provider. Application should include all contract agencies that will be completing the Personal Care Screening Tool on-line. Name ­ Medicaid Certified Provider Name ­ Contact E-Mail Address Medicaid Provider Number Telephone Number

Yes Yes

No No

Will Medicaid Certified Provider be performing Personal Care Screens directly? Is Medicaid Certified Provider already established as an agency for Adult Long Term Care Functional Screen, Children's Long Term Support Screen and/or the Mental Health/AODA Screen? Will contract agencies be conducting Personal Care Screens on behalf of the Medicaid Certified Provider? If yes, complete the information below. Will Medicaid Certified Provider want electronic access to Personal Care Screens conducted by contract agencies?

Yes

No

Yes

No

List agency name and contact information for each agency that will be conducting Personal Care Screens on behalf of the Medicaid Certified Provider (attach additional sheet if necessary). Name ­ Agency Name ­ Contact Telephone Number Name ­ Agency Telephone Number Name ­ Agency Telephone Number Name ­ Agency Telephone Number Name ­ Agency Telephone Number E-Mail Address E-Mail Address Name ­ Contact E-Mail Address Name ­ Contact E-Mail Address Name ­ Contact E-Mail Address Name ­ Contact

Submit Application to:

Gail Propsom preferably via e-mail or fax E-mail: [email protected] FAX: 608/267-2913 Address: DHS/DLTC, Room 450 P.O. Box 7851 Madison, WI 53707-7851